BLD-19-000711 ... Y t'Office Use Only y
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r.; o R g
;'Z';; Permit#
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H�, lid Permit expire 180 days from
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EXPRESS BUILDING PERMIT APPLICATI E C E 1 V E o
. TOWN OF YARMOUTH • i
Yarmouth Building Department AUG 03 2018 1
1146 Route 28 _ _ • P !
South Yarmouth, MA 02664 Bu7�y��c,} t,fj_ r
6e 11-e V UQ�508) 398-2231• / Ext. 1261 °y ( 'lC� l�
CONSTRUCTION ADDRESS: (3 e I e I o e /4✓e S (�GrM oo f I A 6 2 6c1,
- ASSESSOR'S INFORMATION:
• Map: / Parcel: \
OWNER.: Andyy TUurn�Is .Yk Aar Pell-tout. hal O2(dy /
N.4T4E PRESENT ADDRESS TEL. #
CONTRACTOR: TOM '!&'c tIOJ S y i-awe• fro op K? y4/Moill- nv-
NAME MAILING ADDRESS TEL.# Sok *)60 2 is?
El Residential 0 Commercial Est.Cost of Construction$ 7S..rU "
Home Improvement Contractor Lic.# I 1 T 0!} Construction Supervisor Lic.# ' ?-r
Workm 's Compensation Insurance: (check one)
aI am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: C4/4 Worker's Comp.Policy# 6SSfu aO12y-u 37 21 j
' WORK TO BE PERFORMED
Tent — Duration (Fire Retardant Certificate attached?) Wood Stove .
Siding: #of Squares. Replacement windows:# Replacement doors: #
Roofing: #of Squares 2. 2. ( ,)Jemove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing� like for like Pool fencing_ -
•
*The debris will be disposed of at yZ+I M u✓ nit-
yr
Location of Facility -
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) .
will be just cause for denial or revocatio of my license and for prosecution under M.G.L Ch.268,Section 1.
Applicant's Signature:_ Date: r/O// p^ •
Owners Signature(or attachment /�J Date: �,/
Approved By: �>`n...'�/ Date: (� -. x,
g
ctal or designee) EMAIL ADDRESS:
\ Zoning District: .
• Historical District 0 Yes 0 No flood Plain Zone: 0 Yes 0 No . •
Water Resource Protection District Within 100 ft of Wetlands: '
• 0 Yes 0 No 0 Yes 0 No
* A
•
•
The Commonwealth ofMassadlrusetts •
= Department oflndustrialAccidents
E worm Congress Street, Suite 100
Boston, M4 02114-2017
="; www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. .
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): svr4 kr%Va5
Address: Sy Le aux,- era)), P
City/State/Zip: \ rondo 41. h-4 Phone #: SO k 760 2)U
Are you an employer?Check the appropriate box:
Type of project(required):
1.g I am a employer with I employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. g Remodeling
any capacity.(No workers'comp.insurance required.]
• 3. I am a homeowner doingall work myself t 9. ❑ Demolition •
❑ y (No workers'comp.insurance required.]
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors wint no employees.
12.❑Plumbing repairs or additions
5.0i am a general contractor and I have hired the sub-contractors listed on the attached sheet
These sub-contractors have employees and have workers'comp.insurance.: U.0 Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
•
152,$1(4),and we have no employees. [No workers'comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they roust provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site •
information.
Insurance Company Name: ( ^/,,Q
Policy#or Self-ins.Lic.#: 65S4v e 022 wivr7 2/y Expiration Date: D 1 < 115 •
Job Site Address: Ik (3f V.e Vot' Alvt' City/State/Zip: yC✓n,oJik [4 O26CJ
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). •
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cer4;fy under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 92r Date: 8"/'6 I I
Phone*:
Official use only. Do not write in this area, to be completed by city or town official.
•
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
•
A�aCERTIFICATE OF LIABILITY INSURANCE DATE
LM'3�6 I
18
THS CERTIFLCATE lS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES
BELOW. THS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy('es) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such erdorsemenVs).
PRODUCER NAME:CTJULI MCDOWELL
Schlegel S Schlegel Ina Broker PHONE (508) 771-0663
fa Na YAP (5081 771-8381 FAX FAX
34 Main Street 4IaL
West Yarmouth, MA 02673 mnns: schlecelinsurance(?gmail.com
INSURERS)AFFORDING COVERAGE NAC
INSURER A:MOUNT VERNON
INSURED INSURERB:CNA •
TIMOTHY KEATING DBA KEATING INSURER C
CONSTRUCTION INSURER D:
54 LOWER BROOK RD INSURER E:
SOUTH YARMOUTH, MA 02664 INSIIRERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
This IS TO CERTIFY THAT THE POLICES OF INSURANCE USTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDNG ANY REQUIREMENT,TERM CR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TEE POLICIES DESCRIBED HEREN IS SUBJECT TO AU.THE TERMS,
EXCLUSIONS ANO CONDXTIONS OF SUOI POUCES.LIMITS SH01MN MAY HAVE BEEN REDUCED BY PAW CLAIMS,
LTR TYPE OF INSURANCE ADDLSUBR -- POLICY EFT—POLICY EXP-
INSR MND POLICY NUMBER NMIDOIYYYY) (NivtxyYYY) LINTS
A GE.RERALUABII.R1 GL 2548741 3/20!18 3!20119 EACH OCCURRENCE ,S 1.000.000
X COMMERCIAL GEIERALLIABUTY NRA
MAGETOD1 I $ 500.000
ICLAMBMADE I X OCCUR : €DNM one person) $ 10.000
PERSONAL&ADV INJURY $ 1.000.000
GENERAL AGGREGATE f 2.000.000
GEN'LAGGREGGATIELMTAPPLES PER PRODUCTS-C)NIKW AGG $ 2.000.000
pas.,pOI I i& n LOC f
COMBINED SINGLE LIMIT
AUTOMOBILE UABUTY (€aacciart) $
IWYAUTO BODILY INJURY(Pr person) $
ALL OWPED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
'NON-OWNED PROPERTY DAMAGE f
HIRED AUTOS -AUTOS (Per accident)
f
UMBRELIALMB OCCUR EACH OCCURRENCE $
•
EXCESS LIAO CLAMS-MADE AGGREGATE f
DED RETENTION$ f
B %ORKEbCOMPENSATION 6S59UB0224N37214 3/9/18 3/9/19 TORSTA orH-
IND SIPLONERYI.IANL TY
ANY PROPRIETXbPARTNER/EXECUTNE YC�/7N' N)A EL EACH ACODENT S 100.000
g
NattaMt la MB EXCLUDED?
EL.DISEASE-EAEM'LOYEE $ 100,000
Kyee desa=be under EL DISEASE-POLICY LMR $ 500.000
DESCRIPTION OF OPEMTONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHCLES (Mach ACORD 101,M/eanal Rerterla Schedule,It more$Pa Y ngimd)
TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY
•
CERTIFICATE HOLDER CANCELLATION
•
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
l .
0-1988-2 0 COR ORPORATTON. MI rights reserved.
ACORO 25(2014105j The MORD name and logo are registered marks of A O
Phone: Fax: E-Mail:
Keating Construction4
Home improvement contractor registration: DATE May 24,2018
143053
Quotation# 1
54 Lower Brook Rd
So.Yarmouth MA 02664
Phone(508)760 2702
timkeatino66(chhotmail.com Quotation valid until: October 24, 2018
Proposal for: Job name/location:
Andy and Sally Toumas Same
1AAl Bellevue Ave
South Yarmouth Ma
508 398 8824 •
We Nearby submit specificatons and
. . Description.
Strip roof shingles off entire house except back leftside roof
Install 3 ft of ice shield on all lower edge and valleys
Install 30 lb tar paper
Install new vent pipe flanges
Install new white 8 inch drip edge
Install Certainteed Landmark 30 yr architectural shingles
Install ridge vent at all peaks
All debris and trash will be removed and disposed of properly
Only items specified above are included in this proposal.
Chimney flashing replacement is not included in this proposal
Rotted wood repair is not included in this proposal.
Materials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years.
We propose hereby to furnish materials and labor for the sum of: $7,950.00
Senior Citizens discount included
1/3 payment due at start of job and remainder upon completion
Acceptance of Proposal: Date of acceptance: 6 I t
Acceptance of Proposal: tirre0C/fge Date of acceptance:
The above prices,specifications and conditions are satisfactory and are hereby accepted.
Commonwealth of Massachusetts
V) Division of Professional Licensure
Board of Building Regulations� and Standards
ConstructiO Sl}rMf' ?r Specialty
CSSL-099351r.' jay ires: 05/11/2020
7
TIM B KEATING ' '1e� " 'sit iViii
r
54 LOWER BRO„.0K R C - r_', y a
SOUTH YARM60/TH MA=' 2554 . c
‘ cis 13Oa
Commissioner CIL
Je` irnrnonupalrA Office of Consumer Aftao`llajjarAuJem
Business Regulation
HOME IMPROVEMENT CONTRACTOR
E
TYPE:Individual
R9at ttan Expitasn
14305
143053 06/13/2020
TIMOTHY KEATING_-
DB/A KEATING CONST. � , �,
",
TIMOTHY B.KEATING 612-`-,.�0"J
54 LOWER BROOK RD. u
SO.YARMOUTH,MA 02664 Undersecretary